Charles E. Levy, MD; David L. Omura, DPT, MHA; Paul Hoffman, MD; Diane Cowper-Ripley, PhD; Huanguang Jia, PhD; William Mann, PhD

collarlimabeansSécurité

23 févr. 2014 (il y a 3 années et 7 mois)

75 vue(s)

Charles E. Levy, MD; David L. Omura, DPT, MHA; Paul Hoffman, MD; Diane
Cowper
-
Ripley, PhD; Huanguang Jia, PhD; William Mann, PhD


PMRS RORC NF/SGVHS; Veterans Rural Health Resource Center


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Special Thanks


David Charland, PT


Denise Lynn, RT


Jamie Hicks, OT


Sandra Winkler, PhD, OTR/L

Low ADL Monitoring Program

LAMP

History of LAMP



2002 VISN
-
8 Community Care Coordination Service
(CCCS) 2 year clinical demonstration project


Based on preliminary work performed by William Mann,
PhD, Chair of Occupational Therapy at University of
Florida


Demonstrated that functional decline in elders may be
attenuated through the provision of assistive technology and
adaptive equipment (W.C. Mann
et al
., 1995; W.C. Mann
et
al
., 2001; W.C. Mann
et al
., 1999)


Became a NF/SG locally funded PM&RS Telerehabilitation
Care Coordination Home Telehealth program in 2004


LAMP Eligibility Requirements




Require assistance with at least two basic ADLs


Receive medical care from a NF/SG VA PCP


Reside at home


Have electricity and telephone or computer service


Agree to participate in and have the need for
remote monitoring

LAMP Services



Evaluation of functional status


Home assessment for adaptive equipment and
environmental modifications


Training and education to enhance daily
functional performance


Installation of adaptive equipment


Daily remote monitoring of health and functional
status via Health Buddy or computer


Encourage self
-
management of chronic illnesses


Referrals for additional VA and community
services


Continuous care coordination and support


Bathroom
Modifications

Exterior
Modification

Remote Monitoring Technology



Health Buddy


Messaging and monitoring device



Remote Monitoring Technology



Computers with internet capability


Secure custom webform completed and submitted by
veteran and/or caregiver

Remote Monitoring Technology



Computers with internet capability (cont.)


Secure two
-
way asynchronous free text messaging


LAMP Cumulative Data


Total referred: 1727


Total discharged: 467


Total currently enrolled: 221


Total using Health Buddies: 61


Total using computers: 159

LAMP at 1 Year


Care coordination means more prosthetic expenses,
and more clinic visits


Dramatic reduction in nursing home bed days of care


Impact on health is probably best measured in a longer
time span.


High patient satisfaction


Spurs to Innovation


Low Activities of Daily Living Program (LAMP)


OT home assessment, ongoing care coordination, but
not ongoing OT


mTBI/PTSD in returning combat veterans


How to deliver cognitive therapy and support at a
distance


Exercise and Mobility for MS/SCI/Parkinson

s etc.


How to continue to encourage activity and mobility
away from the SCI clinic

Primary Objective



To enable access, and to deliver high
quality rehabilitation to rural veterans
using a telehealth approach.

Critical Step: Implementation:
VHS
Advanced Encryption
Standards, HIPPA




Tandberg E 20


AES, DES, H.233, H.234 and H.235 with an extended
Diffie
-
Hellman key
distribution on H.323, H.320 and leased lines



Summit Software


Real
-
time, authenticated, point
-
to
-
point encrypted video conferencing across
standard communication lines. It is capable of
biometric authentication
for
advanced levels of security.


SSE
-
R Serial Data
Encrypter

(Data
Comm

for Business, Inc.)


The
two RS232 serial ports operate at asynchronous speeds as low as 300 bps and
as high as 57.6 Kbps. The SSE
-
R serial interfaces can be configured as RS232, or
RS422/RS485 4
-
wire.


Real time H.264 Encoding and Decoding Using
FFmpeg

and
x264



E
mploys
video compression and transmission
testbed
, i.e., H.264
realtime

encoding, transmission, and decoding using two open source projects
FFmpeg

and x264.



Telehealth Infrastructure

RVTRI Processes

In order meet the goals established, the RVTRI team implemented the
following:




Collaboration to ensure uniform vision and implementation:


Local, VISN, and Central Office Support Obtained.



Cost analysis to have a private, secure network created:


Private Network
vs
. Local Network
vs
.

National Network


Testing of Telehealth Equipment:


Tandberg E20, Tandberg 1700 and Webcams (Movi 2)



Streamlining of Consults and Provider Profiles:


Use 100% electronic data to perform data mining, evaluation of


initiative progress, and ease of use in providers external to the


demonstration project.



Multifaceted approach to Hiring Staff:


Local HR vs. Contract Staffing vs. Existing Staff


Scapular Strengthening


Veteran

s Experience


Therapist

s Perspective


RVTRI: Project Enrollee Data

184

Veterans:
Identified as
Needing Ongoing
Care

205

Initial
Evaluations
Completed

21

Veterans:
Discharged post
Evaluation: Care
not Warranted

32

Veterans:
Not Interested

152

Veterans:
Received
Tandberg

25

Veterans:
Connectivity
Issues

127

Veterans:
Received
follow
up care via
Tandberg

22
Veterans:
Unable to see
for entire
treatment plan

105

Veterans:
Receiving
telerehab

based
on
inital

POC

55

Veterans:
Telerehab

services
completed

50

Veterans:
Receiving ongoing
care

RVTRI: Workload Capture (Credit Pairs)

CREDIT PAIR:

Encounters

Visits

Uniques

118202 HOME TREATMENT
-
SER/RECREATION THERAPY

25

25

23

118205 HOME TREATMENT
-
SER/PHYSICAL THERAPY

6

6

6

118206 HOME TREATMENT
-
SER/OCCUPATIONAL THER

11

11

10

201179 PHYSICAL MED & REB/RT CLIN VID CARE

1

1

1

202179 RECREATION THERAPY/RT CLIN VID CARE

245

245

48

202483 RECREATION THERAPY /RURAL HOME CARE

193

173

94

205179 PHYSICAL THERAPY/RT CLIN VID CARE

761

760

107

205483 PHYSICAL THERAPY/RURAL HOME CARE

466

456

179

205690 PHYSICAL THERAPY/RT CLIN VID TH PAT

11

11

11

205692 PHYSICAL THERAPY/RT CLIN VD TH PRV

43

36

32

206179 OCCUPATIONAL THER/RT CLIN VID CARE

136

135

40

206483 OCCUPATIONAL THERAP/RURAL HOME CARE

236

234

120

REPORT TOTAL:

2134

1921

292

RVTRI: Coverage Area



137 Rural Zip Codes
in the NF/SG VHS




30% (40/137) of all
Rural Zip Codes were
served by RVTRI staff.





RVTRI: Data Assessment

Functional Independence Measure (FIM):


Rates assistance needed on 18 items (self
-
care,
sphincter control, transfers, locomotion,
communication, and social cognitionusing) using a 7
point scale per each item.


Range: 18
-
126


Wilcoxon Signed Rank Test Conducted on Data

Veterans Rand 12 Item
Health Survey (VR
-
12):



VR
-
12 is a brief, generic, multi
-
use, 12 items
instrument measuring health related quality of
life.
Based on how a veteran feels emotionally and
physically at a point in time .


Wilcoxon Signed Rank Test Conducted on Data

Quick Dash


11 item instrument to measure upper limb physical
function and symptomatology.

The lower the
percentage of disability the better the identified
outcome.


Wilcoxon Signed Rank Test Conducted on Data

The Montreal Cognitive Assessment
(MoCA)


Rapid screening instrument for mild cognitive dysfunction. It assesses
different cognitive domains: attention and concentration, executive
functions, memory, language, visual constructional skills, conceptual
thinking, calculations, and orientation.


Time to administer the MoCA is approximately 10 minutes. The total
possible score is 30 points; a score of 26 or above is considered normal.

Wilcoxon Signed Rank Test Conducted on Data

2 Minute Walk Test


Veterans are given instruction to walk as far as
they can, stopping to rest if needed.


Wilcoxon Signed Rank Test Conducted on Data

Other Metrics of Interest

Category Title

Number

Range or Total
Number

AVG Miles Driven per Veteran (One Way)

93 Miles

10.4 Miles to
145
Miles

AVG Miles Driven per Veteran (Roundtrip)

186 Miles

20.8 Miles to
290
Miles

AVG Total Miles Driven per Veteran

1147 Miles

130,767 Miles

AVG Number of Visits per Veteran

7 Visits

One to 24 Visits

AVG VA Travel Expense per Veteran

$477.23

$54,926.00

AVG Total Hours Saved per Veteran

18.95 Hours

2,179.45 Hours

Veteran

s Impressions

QUESTIONS


AVG SCORE

1.) Satisfaction
Level
-

Length of Time for your First Appointment?

3.66/4

2.) How
long did you have to Wait to see your Provider?

1.02/5

3.)

Satisfaction
Level
-

Length of Time spent with Specialist?

3.71/4

4.) Satisfaction
Level
-

How would you rate your Healthcare Provider's
Personal Manner?

4.76/5

5.) My
Provider gave me an Opportunity to Ask Questions?

4.97/5

6.) Satisfaction
Level
-

How you felt your Privacy was Respected?

3.92/4

7.) Future
Intentions: Would you come back to this clinic for additional care?

4.76/5

8.) Satisfaction
Level
-

How well was the Equipment Operation explained?

3.84/4

9.) Satisfaction
Level
-

Video Quality?

3.39/4

10.) Satisfaction
Level
-

Audio Quality?

3.47/4

11.) Satisfaction
Level
-

Understanding the Specialist?

3.79/4

12.) Satisfaction
Level
-

Overall Telehealth Experience?

3.68/4

13.) Would
you use Telehealth again to receive Medical care in the Future?

1.08/2


Locations
:


Lake City Medical Center to Jacksonville OPC (RT)


Lake City Medical Center to Marianna CBOC (LPN)


Lake City Medical Center to Tallahassee CBOC (pending)



Services Offered
:


Evaluation of Mobility Aides (walkers, canes, etc.)


Evaluation of TENS units


RVTRI: Clinical Video Telehealth (CVT)

RVTRI: Clinical Video Telehealth (CVT)


Profiles Established using Appropriate Credit Pairs
:


205 (Physical Therapy) 690 (CVT Patient Site)


205 (Physical Therapy) 692 (CVT Provider Site)



Average Number of Veterans Treated/8 Hour Day
:


11.5 veterans



Satisfaction of Veterans (117 Completed)
:


Would you come back to this clinic for future care?: 4.81/5.00


Satisfaction Level: Video Quality: 3.61/4.00


Satisfaction Level: Audio Quality: 3.76/4.00









SR Champions Award
Outpatient Category:

2
nd

Place


Charles E. Levy, Chief PMRS, Assoc. Dir., RORC


David Omura, PMRS Mgr., Affiliate Researcher RORC


Paul Hoffman, Dir., Vets Rural Health Res Ctr., East Region


Nick Ross, Asst. Director, NF/SG VHS


Bill Mann, Director, RORC


Huanguang Jia, Research Health Specialist, RORC


Diane Cowper, Assoc. Dir., RORC


Steve Moore, Information Technologist, PMRS


Thomas A. Cappello, Director, NF/SG VHS



Prerequisites


1) A practice that can be performed remotely


2) Practitioners


3) Space


4) IT support


5) Workload capture/coding


6) Outcome Measures

Office of Rural Health


http://www.ruralhealth.va.gov/index.asp


Mary Beth Skupien, PhD, MS, RN

Director, Office of Rural Health


Paul Hoffman, MD

Director of the Veterans Rural Health Resource
Center
-

Eastern Region



Peter Kaboli, MD, MS

Director of the Veterans Rural Health Resource
Center
-
Central Region



Byron Bair, M.D.

Director of the VA Rural Health Resource Center


Western Region


ORH FYI 2011 Projects

VHA Office of TeleHealth


http://www.telehealth.va.gov/

Office of Information

and Technology


Jeff Day, Director, VACO IT Support for IP
Convergence


VideoTeleconferencing, Network andUnified
Communications


Jeffrey.day@va.gov

Contact Us


charles.levy@va.gov


david.omura@va.gov

Next Steps

Tablets:


Virtual Environments for Therapeutic
Solutions (VETS) mTBI/PTSD Phase I & II


VA RR&D: 1I01RX000339
-
01A3


Charles E. Levy,
1,
-
3
; James Oliverio
3
, Jill Sonke
4
, Thomas
Hundersmarck
2

, Jason Demery
2
, Christian Tassin
3
, Arturo
Sinclair
3
, Hellena Scott
-
Okafor
2

and David Omura
2 ,

1
North Florida Foundation for Research and Education,
2
North
Florida/South Georgia Veterans Health System,
3
Digital
Worlds Institute, University of Florida;
4

Center for Arts in
Healthcare Research & Education, University of Florida,
Gainesville, Florida


This work was supported by:
CDMRP/DoD Concept Award: Design of Effective therapeutic interventions for Mild TBI/PTSD
using interactive Virtual World Environments, 9.15.08
-
9.14.09, PI: Charles E. Levy, MD


Acknowledgements


Lokesh Bhoobalan


Nandhini Giri


Charan Guttaplem



Therapeutic Virtual

Environments/Virtual Humans


Easy Access From Home


Well Accepted by Younger Warriors Familiar with Video
Gaming


Safe, Controlled Environment


Infinite Repetitions = Infinite Practice


Play Back to Examine Different Points of View


Eliminates Travel


Cognitive and Emotive Challenges


Scalable Task Complexity


Scalable Distracters


Recursive/Iterative Process


Clinical Team: (NF/SG VHS) 3 Physiatrists, 2
Neuropsychologists, 1 OT, 1 PT, 1 clinical psychologist, 1
ARNP,


Technical Team


1) Digital World Institute at UF: Professor James Oliverio


2) Virtual Experiences Research Group at UF: Ben Lok,
PhD: Shadow Learning: Aaron Kotranza, PhD


Advisory Team



Product: Virtual Grocery Store


Cognitive Challenges:


Organize lists


Find items


Budget, pay, monitor interaction


Emotive Challenges


Interactions with shoppers,cashiers


Distracters


Noise,


amount and appearance of other shoppers


VE Creation: Shopper


Pushing a Cart


Number of Bots


Unexpected Incident


What Therapists Do


Virtual and Mixed Reality Humans

Cashier


Thanks For Your Attention!